Clinical Medicine Insights. Case Reports最新文献

Introduction: Tuberculosis (TB) remains a leading infectious disease worldwide, with Ethiopia among the highest-burden countries. Laryngeal tuberculosis is rare, accounting for less than 1%-2% of TB cases and typically affects the posterior glottis and true vocal cords. However, atypical involvement of the subglottic region is uncommon and can closely resemble laryngeal carcinoma both clinically and radiologically, posing a significant diagnostic challenge.

Case presentation: We report a 64-year-old man with a 1-year history of progressive hoarseness. Neck CT demonstrated asymmetric mucosal thickening and enhancement of the glottis with anterior subglottic extension, along with a rim-enhancing necrotic prelaryngeal node which are findings highly suggestive of malignancy. Chest CT revealed right upper lobe cavitation, nodularity and tree-in-bud opacities consistent with active pulmonary tuberculosis. GeneXpert MTB/RIF confirmed Mycobacterium tuberculosis, and laryngeal biopsy revealed caseating granulomatous inflammation with acid-fast bacilli. A diagnosis of concomitant pulmonary and laryngeal tuberculosis was established, and the patient was started on standard first-line anti-tubercular therapy.

Discussion: Laryngeal tuberculosis typically involves the posterior glottis, but in this case, anterior subglottic disease with necrotic nodal involvement created strong radiologic overlap with carcinoma. Recognition of such atypical patterns is crucial, especially in endemic regions, as misdiagnosis may lead to unnecessary surgical interventions.

Conclusion: Persistent hoarseness with mass-like laryngeal lesions should prompt consideration of tuberculosis in endemic settings. Radiologists play a key role in identifying suggestive features and integrating them with pulmonary imaging and microbiologic results to ensure accurate diagnosis and timely treatment.

Background: Lemierre's syndrome is a rare but life-threatening condition characterized by septic thrombophlebitis, most often due to Fusobacterium necrophorum. Although uncommon, Staphylococcus aureus can also cause atypical and severe presentations.

Case presentation: This case describes an unusual presentation of Lemierre's syndrome in an 18-year-old male, associated with Staphylococcus aureus and complications including left-sided secondary spontaneous pneumothorax, septic pulmonary emboli, and pleural effusion. The patient initially presented with fever, headache, periorbital swelling with double vision, neck pain, and acute onset left-sided chest pain with shortness of breath. Initial evaluations revealed thrombosis in the superior ophthalmic veins, cavernous sinuses, and bilateral internal jugular veins, along with left-sided pneumothorax and diffuse cavitating nodules in both lung fields. Blood cultures confirmed Staphylococcus aureus resistant to macrolides. Treatment includes high-flow oxygen, intravenous vancomycin followed by oxacillin, and anticoagulation therapy. At 3-month follow-up, the patient had fully recovered with resolution of pneumothorax and inflammatory markers.

Conclusion: This case highlights the importance of recognizing atypical presentations of Lemierre's syndrome and the need for prompt multidisciplinary intervention to prevent fatal outcomes.

Introduction: Burkitt lymphoma (BL) is a highly aggressive B-cell non-Hodgkin lymphoma that typically presents with abdominal masses; ampullary involvement with obstructive jaundice and gastrointestinal bleeding is exceptionally rare in children. Early biliary decompression can be crucial to permit timely chemotherapy.

Case presentation: A 14-year-old boy presented with 1 week of worsening abdominal pain, non-bilious vomiting, constipation, jaundice, and melena. Examination showed pallor, icterus, firm hepatomegaly, and a palpable epigastric mass. Laboratory testing revealed cholestatic liver function abnormalities and elevated pancreatic enzymes. Ultrasound and contrast computed tomography demonstrated a large retroperitoneal mass compressing the biliary tree. Upper gastrointestinal endoscopy identified a friable, ulcerated ampullary mass with active bleeding. Biopsy confirmed BL by morphology (starry-sky) and immunohistochemistry/fluorescence in situ hybridization (CD20+, CD10+, c-MYC+, Ki-67 ~95%). Main diagnosis made was pediatric BL presenting with ampullary involvement causing obstructive jaundice and upper gastrointestinal bleeding. Given persistent cholestasis and bleeding risk, the patient underwent Roux-en-Y choledochojejunostomy for biliary decompression, followed by initiation of rituximab-cyclophosphamide-vincristine-doxorubicin-high-dose methotrexate/rituximab-ifosfamide-etoposide-high-dose cytarabine (R-CODOX-M/R-IVAC) with central nervous system prophylaxis. Post-operative bilirubin improved, and early chemotherapy cycles were tolerated. During the 2-week hospitalization, the patient had symptomatic improvement; however, objective radiologic response could not be documented because care was transferred and post-transfer positron emission tomography-computed tomography was unavailable.

Conclusion: Ampullary BL should be considered in pediatric patients with obstructive jaundice and upper gastrointestinal bleeding. Surgical biliary decompression can stabilize cholestasis and facilitate timely multi-agent chemotherapy.

Background: Renal angiomyolipomas (AMLs) are benign renal tumors arising from perivascular epithelioid cells and are often associated with tuberous sclerosis complex. Renal epithelioid angiomyolipoma (EAML) is a rare variant of AML, characterized by the predominance of epithelioid cells with malignant potential. Although EAML is typically seen in adults, especially females, its occurrence in children is extremely rare and can be difficult to distinguish from other renal tumors.

Case presentation: We report a case of an 8-year-old girl with a right renal mass that initially was suspected to be a Wilms tumor based on imaging results and was treated with Wilms-directed chemotherapy without response. Histopathological investigations after a radical nephrectomy revealed an EAML composed primarily of epithelioid cells. Immunohistochemistry confirmed the diagnosis with positive results for HMB45 and Melan-A, highlighting the importance of histopathological and immunohistochemical evaluation in pediatric renal masses with atypical clinical behavior.

Conclusion: Renal epithelioid angiomyolipoma should be considered in pediatric renal masses with atypical imaging features or poor response to Wilms tumor chemotherapy. Accurate diagnosis relies on histopathological and immunohistochemical evaluation, which helps guide appropriate surgical management and postoperative surveillance due to the tumor's variable malignant potential.

Introduction: Mycoplasma pneumoniae infection commonly causes mild respiratory illness, but cold agglutinin syndrome (CAS) is an uncommon extrapulmonary complication. CAS typically results in mild, predominantly extravascular hemolysis; however, severe intravascular hemolysis and acute kidney injury (AKI) are rare.

Case presentation: A 59-year-old woman presented with profound weakness, jaundice, dark urine, and anuria following a mild upper respiratory illness. Laboratory evaluation revealed severe intravascular hemolysis, markedly elevated LDH activity, undetectable hemoglobin (Hb) level, hemoglobinuria, and AKI. Direct antiglobulin testing was positive for C3d only, and the cold agglutinin titer was markedly elevated (1:2048). Mycoplasma pneumoniae IgM serology was positive. She required warmed blood transfusions, antibiotics, thermal protection, and continuous renal replacement therapy. Over 10 days, hemolysis-related laboratory parameters and serum creatinine level improved significantly.

Conclusion: This case illustrates a rare and severe form of Mycoplasma pneumoniae-associated CAS presenting with massive intravascular hemolysis and AKI. Early recognition and supportive interventions-particularly warmed transfusions and renal support-were critical to recovery. Clinicians should consider cold agglutinin-mediated hemolysis in patients with dark urine and AKI following respiratory infection.

Background: Foreign body aspiration (FBA) in adults is rare and often overlooked, presenting with nonspecific pulmonary symptoms that may mimic recurrent infections or malignancy. Delay in diagnosis can lead to prolonged morbidity and mismanagement.

Case presentation: We report a 55-year-old woman with a 2-month history of productive cough, intermittent hemoptysis, dyspnea, pleuritic chest pain, and recurrent pneumonia unresponsive to multiple courses of antibiotics and corticosteroids. Chest X-ray revealed right middle-lobe collapse, while computed tomography demonstrated a linear radiopaque lesion in the right middle-lobe bronchus. Flexible bronchoscopy confirmed complete bronchial obstruction by purulent debris concealing a sharp chicken bone fragment, which was retrieved successfully. The patient showed rapid clinical improvement following removal.

Conclusion: This case underscores the importance of considering FBA in the differential diagnosis of persistent atelectasis or treatment-resistant pneumonia in adults, even in the absence of aspiration history or risk factors. Diagnostic bronchoscopy remains the gold standard, enabling both definitive diagnosis and therapeutic intervention, thereby preventing misdiagnosis as neoplasm and avoiding unnecessary procedures.

Invasive ductal carcinoma (IDC) is the most common subtype of breast cancer. While malignant wounds are known to predispose patients to secondary infections, the co-occurrence of cutaneous myiasis in breast carcinoma remains rare. We report the first documented case of wound myiasis in a patient with advanced breast carcinoma in Bangladesh. A 52-year-old woman with HER2-positive IDC of the right breast, previously treated with mastectomy, chemotherapy, and radiotherapy in a tertiary care hospital of Dhaka, presented to the Department of Palliative Medicine at Bangladesh Medical University with severe chest wall pain, facial swelling, and a foul-smelling ulcerated wound on her right chest wall on mastectomy site, infested with live maggots. The patient had advanced stage 4 disease with extensive skin and bony metastasis, stage 3 lymphedema, and a Palliative Performance Scale score of 30%, indicating an estimated survival of 8 to 41 days. Approximately 650 larvae were removed over 3 days through manual extraction and irrigation using saline, metronidazole, and turpentine, followed by occlusive dressing with petroleum gauze. She was treated with morphine, flucloxacillin, ivermectin, and albendazole, which resulted in significant symptomatic relief. This case highlights the complex intersection of advanced malignancy, socioeconomic deprivation, poor hygiene, and parasitic infestation. Palliative care played a critical role in pain relief, wound management, and preserving dignity in her final days. This report underscores the importance of early recognition and integrated management of malignant wound myiasis, particularly in resource-constrained environments. It also draws attention to the broader psychosocial impacts of such conditions and the essential role of end-of-life care in mitigating suffering.

Introduction: In the acute neurology setting, stroke presentations are considered common relative to other diagnoses, especially among multimorbid elderly presenting with acute neurological changes. Clinicians tend to underestimate the possibility of other rare diagnoses such as brain tumors.

Case report: Here we present a case report of an 80-year-old female who presented to the emergency department, she exhibited a seizure and stroke-like symptoms, including confusion, loss of consciousness, and slurred speech. Initial clinical assessments suggested a cerebrovascular event; however, neuroimaging later revealed a parasagittal meningioma as the cause of the symptoms.

Conclusion: This case underscores the necessity of including brain tumors such as meningiomas in the differential diagnosis for elderly patients presenting with symptoms resembling cerebrovascular events.

Duodenal obstruction in the setting of situs inversus abdominis is an uncommon clinical finding. We report 2 neonates who presented with bile-stained vomiting and abdominal distension. Diagnostic workup, including radiography and ultrasonography, confirmed the diagnosis of situs inversus abdominis with duodenal obstruction due to annular pancreas in the first case and due to intestinal malrotation in the second. A Ladd's procedure was successfully performed to relieve the obstruction. Both patients recovered well, initiating full enteral feeds and were subsequently discharged. These cases underscore the diagnostic challenges posed by this rare association and highlight that a standardized surgical approach, adapted to the mirror-image anatomy, can lead to a successful outcome. Early recognition and tailored intervention are crucial in the management of these complex patients.

Background: Myocardial bridging (MB) is a congenital coronary artery anomaly in which a segment of an epicardial coronary artery, most commonly the left anterior descending (LAD) artery, courses intramyocardially, and undergoes systolic compression. Although historically regarded as a benign anatomical variant, myocardial bridging has increasingly been recognized as a potential cause of myocardial ischemia, exertional chest pain, and other cardiac symptoms, particularly in patients without obstructive coronary artery disease. Awareness of this condition is important, as its diagnosis and management differ from those of atherosclerotic coronary disease.

Case presentation: We report 2 cases of symptomatic myocardial bridging involving the mid-segment of the LAD artery. The first case involved a 35-year-old male with a 2-month history of exertional chest pain and no cardiovascular risk factors. Initial evaluation, including electrocardiography, cardiac biomarkers, and transthoracic echocardiography, was unremarkable. Coronary angiography demonstrated a myocardial bridge in the mid-LAD with systolic compression and normal diastolic filling, without evidence of obstructive coronary artery disease. The patient was treated with diltiazem, resulting in complete symptom resolution at 1-month follow-up. The second case involved a 48-year-old male with a history of smoking and well-controlled hypertension who presented with exertional chest pain radiating to the left arm, accompanied by palpitations. Laboratory investigations, electrocardiography, and echocardiography were normal. Coronary angiography again revealed myocardial bridging of the mid-LAD without obstructive lesions. Treatment with diltiazem led to complete symptom resolution, and the patient remained clinically stable at 2-month follow-up.

Discussion: These cases highlight the clinical significance of myocardial bridging as a cause of angina-like symptoms in patients with non-obstructive coronary arteries. The pathophysiology is multifactorial and includes dynamic systolic compression, delayed diastolic relaxation, endothelial dysfunction, and increased susceptibility to ischemia during tachycardia. Medical therapy aimed at reducing heart rate and myocardial contractility, particularly with non-dihydropyridine calcium channel blockers, remains the cornerstone of management.

Conclusion: Myocardial bridging should be considered in the differential diagnosis of chest pain in patients with normal coronary arteries. Early recognition and appropriate medical therapy can result in effective symptom control and may prevent unnecessary invasive interventions.